A prospective cross-sectional study on hypocalcemia after total thyroidectomy in patients with Graves' disease: insights on secondary hyperparathyroidism.

PURPOSE: To investigate the parathyroid function and calcium (Ca) levels in the secondary hyperparathyroidism (SHPT) state in patients with Graves' disease. METHODS: We examined 31 consecutive patients with Graves' disease without chronic kidney disease, who were treated with total thyroidectomy. The patients were divided into a normal parathyroid hormone (PTH) group (NPTH group; n = 19) with a PTH level ≤ 65 pg/mL, and a secondary hyperparathyroidism group (SHPT group; n = 12), with a PTH level > 65 pg/mL. The PTH and Ca-related parameters were examined and the risk factors for postoperative hypocalcemia were analyzed. RESULTS: The preoperative Ca level was significantly lower (2.24 ± 0.06 vs. 2.31 ± 0.07 mmol/L, p < 0.05) in the SHPT group than in the NPTH group. The reduction in PTH, 1,25-dihydroxyvitamin D (1,25(OH)2D), and Ca levels from the preoperative day to the next morning was significantly greater in the SHPT group than in the NPTH group (p < 0.05). When intraoperative factors were included, the decrease in the PTH level alone was significant. SHPT was a significant factor in determining the extent of PTH reduction. CONCLUSIONS: Hyperfunctioning parathyroid glands in the SHPT state were more susceptible to postoperative PTH reduction, which, combined with low preoperative Ca levels, increased the risk of postoperative hypocalcemia in patients with Graves' disease.

Versican controlled by Lmx1b regulates hyaluronate density and hydration for semicircular canal morphogenesis.

During inner ear semicircular canal morphogenesis in zebrafish, patterned canal-genesis zones express genes for extracellular matrix component synthesis. These include hyaluronan and the hyaluronan-binding chondroitin sulfate proteoglycan Versican, which are abundant in the matrices of many developing organs. Charged hyaluronate polymers play a key role in canal morphogenesis through osmotic swelling. However, the developmental factor(s) that control the synthesis of the matrix components and regulation of hyaluronate density and swelling are unknown. Here, we identify the transcription factor, Lmx1b, as a positive transcriptional regulator of hyaluronan, Versican, and chondroitin synthesis genes crucial for canal morphogenesis. We show that Versican regulates hyaluronan density through its protein core, whereas the charged chondroitin side chains contribute to the osmotic swelling of hyaluronate. Versican-tuned properties of hyaluronate matrices may be a broadly used mechanism in morphogenesis with important implications for understanding diseases where these matrices are impaired, and for hydrogel engineering for tissue regeneration.

Wide-Awake Tenolysis for Tendon Entrapment in a Distal Radial Epiphyseal Separation (Volar Displacement Type): A Case Report.

The patient was a 13-year-old male who fell while riding a bicycle and was initially diagnosed with a distal radial epiphyseal separation (volar displacement type) that was conservatively managed. Four months post-injury, he complained of limited movement in his left index finger and was referred to our hospital. Upon examination, the patient also complained of limited movement of the left index finger in wrist flexion. The wrist range of motion was 50° of volar flexion, 50° of dorsiflexion, 90° of pronation, and 90° of supination with the fingers extended. The X-ray revealed a radiolucent area in the distal radius. Ultrasound, computed tomography, and magnetic resonance imaging scans demonstrated entrapment of the extensor tendon within the medullary cavity of the radius. Five months post-injury, surgery was performed using the wide-awake local anesthesia no-tourniquet (WALANT) technique. A dorsal wrist approach was utilized, and the extensor digitorum communis tendon was found to be trapped within the medullary cavity of the radius. The tendon was released using an air drill, and sufficient improvement in the left index finger flexion was confirmed with active movement before concluding the surgery. At the 11-month postoperative follow-up, the patient showed excellent outcomes with a wrist range of motion of 75° of volar flexion, 85° of dorsiflexion, 90° of pronation, and 90° of supination. Tendon entrapment of the extensor tendons has been reported as a long-standing complication associated with distal radius fractures, particularly with volar displacement types. A benefit of the WALANT technique is the ability to communicate with the patient during surgery, allowing for active movements of the fingers and wrist. This is particularly useful in tendon surgeries for determining tendon tension. We report a case of successful tenolysis surgery using the WALANT technique for a patient with a conservatively managed distal radial epiphyseal separation (volar displacement type), who experienced a limited flexion of the index finger due to tendon entrapment.

Intraoperative parathyroid hormone measurement pitfalls: parathyroid hormone spikes with carboxyl-terminal parathyroid hormone fragments in primary hyperparathyroidism-a case report.

BACKGROUND: Intraoperative parathyroid hormone (IOPTH) monitoring is a critical surgical adjunct for determining the extent of surgery for primary hyperparathyroidism (PHPT), with reported false-positive and false-negative rates of up to 10%. Surgeons must understand the parathyroid hormone (PTH) dynamics and select the appropriate IOPTH protocol and interpretation criteria for curative surgery. CASE PRESENTATION: We present the case of a 64-year-old woman with a large cystic parathyroid tumor and PHPT who experienced a significant delay in IOPTH decrease but was cured without additional surgery. The patient's basal intact PTH was 96.2 pg/mL, which decreased to 93.3 pg/mL at 25 min and 72.4 pg/mL at 55 min after removal of the parathyroid tumor. In an attempt to elucidate its pathophysiology, 1-84 PTH levels were measured in stored serum. These results can also be attributed to the relatively low basal PTH levels, intact PTH spike, and high ratio of large carboxyl-terminal PTH fragments present. The patient had normal intact PTH and calcium levels at the 9-month postoperative visit. CONCLUSIONS: As detailed reports on these phenomena are scarce, we discuss the causes of false-negative IOPTH results in terms of PTH production, secretion, metabolism, and differences in measurement methods to avoid unnecessary surgery.

Spatiotemporal Control of Polymorphic Phase Transition of Glycine Crystals by Three-Dimensional Femtosecond Laser Ablation Processing.

Spatiotemporal control of the polymorphic phase transition of glycine crystals was demonstrated by three-dimensional (3D) processing with a focused femtosecond laser pulse as an external stimulus. We found that the transition from a metastable form (ß-form) to more stable ones (α- or γ-form) could be triggered from the irradiated area of not only the surface but also inside of glycine crystals. This 3D processing with a focused femtosecond laser pulse enabled us to precisely monitor the transition dynamics from a targeted position to the entire part of crystals. The systematic study with the space-selective phase transition method revealed that the phase transition inside of glycine crystals was significantly slower (e.g., ∼50 times) than that at the crystal surface, which indicates the crucial role of water molecules in air on the phase transition dynamics. We foresee that this laser method can be a practical tool for monitoring spatiotemporal dynamics of phase transition.

Significant role of 1,25-dihydroxyvitamin D on serum calcium levels after total thyroidectomy: a prospective cohort study.

Introduction: Although active vitamin D (VD) has been used both preoperatively and postoperatively to prevent hypocalcemia risk in patients undergoing total thyroidectomy, the role of 1,25-dihydroxyvitamin D (1,25(OH)2D) has not been examined. This study comprehensively investigated the effects of 1,25(OH)2D on calcium (Ca) concentrations after total thyroidectomy. Methods: Serum Ca, parathyroid hormone (PTH), and 1,25(OH)2D levels were measured in 82 patients with thyroid disease before and after surgery. Results: Serum Ca, PTH, and 1,25(OH)2D levels decreased significantly on the morning of the first postoperative day. Notably, the decrease in 1,25(OH)2D concentration was significantly lower than that of PTH concentration (10.5 ± 33.4% vs. 52.1 ± 30.1%, p<0.0001), with 28% of patients showing increases in 1,25(OH)2D. The only factor predicting a postoperative 1,25(OH)2D decrease was a high preoperative 1,25(OH)2D concentration. Postoperative 1,25(OH)2D concentrations, as well as the magnitude and rate of decrease from preoperative levels, showed strong positive correlations with preoperative 1,25(OH)2D concentrations (p<0.0001 for all three variables) but not with PTH concentrations. These findings suggest that 1,25(OH)2D concentrations after thyroidectomy were more strongly dependent on preoperative concentrations than on the effect of PTH decrease and were relatively preserved, possibly preventing sudden severe postoperative hypocalcemia. A high 1,25(OH)2D level was the most important preoperative factor for hypocalcemia (<2 mmol/L; p<0.05) on the first postoperative day; however, only PTH decrease was statistically significant (p<0.001) when intraoperative factors were added. In the PTH >10 pg/mL group, the decrease in 1,25(OH)2D levels was significantly associated with postoperative hypocalcemia (p<0.05). Similarly, in the PTH levels >15 pg/mL group, a decrease in 1,25(OH)2D concentration was a significant factor, and the amount of PTH decrease was no longer significant. Conclusion: 1,25(OH)2D plays an important role in preventing sudden, severe hypocalcemia due to decreased PTH levels after total thyroidectomy, whereas high preoperative 1,25(OH)2D levels are a significant risk factor for postoperative hypocalcemia. Optimizing preoperative protocols to adjust Ca, PTH, and 1,25(OH)2D levels to improve the management of patients undergoing total thyroidectomy and to prevent extreme intraoperative PTH decreases may reduce the risk of hypocalcemia.

Alterations in Body Weight and Composition in Patients With Graves' Disease Treated with Total Thyroidectomy.

OBJECTIVE: Thyrotoxicosis causes excess energy expenditure, resulting in weight loss, despite increased appetite, and changes in body composition, which are typically reversible with the normalization of thyroid hormone levels. However, patients with hyperthyroidism due to Graves' disease are sometimes hesitant to undergo treatment because of the perceived morbidity associated with weight gain. Therefore, obtaining data to explain the details of such weight gain to these patients is important. This study aimed to investigate changes in body weight and composition in patients with Graves' disease after total thyroidectomy. METHODS: In total, 21 patients with Graves' disease who underwent total thyroidectomy were enrolled. Among them, nine patients were hyperthyroid (group A) and 12 were euthyroid (group B, control) immediately before surgery. Body weight, height, and body composition using bioelectrical impedance were measured preoperatively and five months postoperatively. RESULTS: In all patients, body weight, body mass index, and skeletal muscle mass, but not fat mass, significantly increased postoperatively. In individual groups, a significant increase in skeletal muscle and fat masses was observed solely in groups A and B, respectively. Furthermore, a significant positive correlation between preoperative thyroid function and differences in skeletal muscle mass preoperatively and postoperatively was found. CONCLUSION: Our study shows that the normalization of thyroid function using thyroidectomy in patients with Graves' disease is accompanied by weight gain, mainly due to an increase in skeletal muscle mass. These data are clinically significant because they enable physicians to explain to patients that weight gain after surgical treatment for Graves' disease is favorable and reassure them of their concern.

The impact of crystal phase transition on the hardness and structure of kidney stones.

Calcium oxalate kidney stones, the most prevalent type of kidney stones, undergo a multi-step process of crystal nucleation, growth, aggregation, and secondary transition. The secondary transition has been rather overlooked, and thus, the effects on the disease and the underlying mechanism remain unclear. Here, we show, by periodic micro-CT images of human kidney stones in an ex vivo incubation experiment, that the growth of porous aggregates of calcium oxalate dihydrate (COD) crystals triggers the hardening of the kidney stones that causes difficulty in lithotripsy of kidney stone disease in the secondary transition. This hardening was caused by the internal nucleation and growth of precise calcium oxalate monohydrate (COM) crystals from isolated urine in which the calcium oxalate concentrations decreased by the growth of COD in closed grain boundaries of COD aggregate kidney stones. Reducing the calcium oxalate concentrations in urine is regarded as a typical approach for avoiding the recurrence. However, our results revealed that the decrease of the concentrations in closed microenvironments conversely promotes the transition of the COD aggregates into hard COM aggregates. We anticipate that the suppression of the secondary transition has the potential to manage the deterioration of kidney stone disease.

Calcium phosphate controls nucleation and growth of calcium oxalate crystal phases in kidney stones.

Kidney stone disease is a serious disease due to the severe pain it causes, high morbidity, and high recurrence rate. Notably, calcium oxalate stones are the most common type of kidney stone. Calcium oxalate appears in two forms in kidney stones: the stable phase, monohydrate (COM), and the metastable phase, dihydrate (COD). Particularly, COM stones with concentric structures are hard and difficult to treat. However, the factor determining the growth of either COM or COD crystals in the urine, which is supersaturated for both phases, remains unclear. This study shows that calcium phosphate ingredients preferentially induce COM crystal nucleation and growth, by observing and analyzing kidney stones containing both COM and COD crystals. The forms of calcium phosphate are not limited to Randall's plaques (1-2 mm size aggregates, which contain calcium phosphate nanoparticles and proteins, and form in the renal papilla). For example, aggregates of strip-shaped calcium phosphate crystals and fields of dispersed calcium phosphate microcrystals (nano to micrometer order) also promote the growth of concentric COM structures. This suggests that patients who excrete urine with a higher quantity of calcium phosphate crystals may be more prone to forming hard and troublesome COM stones.